Recently, the Centers for Medicare and Medicaid Services (CMS) issued a temporary ruling revising the current policy on Part B billing following the denial of a Part A inpatient hospital claim deemed to be medically unnecessary.  The revisions are intended as an interim measure until CMS can finalize an official policy to address the issues raised by the Administrative Law Judge (ALJ) and Medicare Appeals Council decisions going forward.  This temporary ruling is effective until CMS finalizes its proposed rule.  Under the terms of the proposed rule:

When a Part A claim for inpatient hospital services is denied because the inpatient admission was deemed not to be reasonable or necessary, or when a hospital determines under § 482.30(d) or § 485.641 after a beneficiary is discharged that his or her inpatient admission was not reasonable and necessary, the hospital may be paid for all the Part B services (except for services that specifically require an outpatient status) that would have been reasonable and necessary had the beneficiary been treated as a hospital outpatient rather than admitted as an inpatient, if the beneficiary is enrolled in Medicare Part B.

While the CMS ruling currently concurs with the ALJ and Appeals Council rulings to award Part B payment as timely if the original Part A claim was timely, the proposed rule would reverse this ruling and require inpatient Part B claims be filed within the one-year timely filing period.

To read more or to provide comments to CMS, go to:  https://www.federalregister.gov/articles/2013/03/18/2013-06163/medicare-program-part-b-inpatient-billing-in-hospitals

In Transmittal 2449 (released April 26, 2012 and effective October 1, 2012) CMS revised regulations affecting the Common Working File, FISS, MCS, and VMS regarding the use of beneficiary names in Medicare claims processing. The beneficiary name on a Medicare claim must now exactly match the name and HICN in the Common Working File. Claims submitted with a mismatch will be returned to the provider with a disposition code 55 and error code 5052. In the past, information that was believed to be the proper patient identification was returned to the provider; this information will no longer be provided.

To avoid returned claims and possible denials, providers should make certain that all information, including date of birth, punctuation, and suffixes, appears exactly as it appears on the patient’s Health Insurance Identification Card.

CMS is making a significant change to the Medically Unlikely Edits (MUE) by changing the edits from line item edits to date of service edits. The change will become effective April 1.

An MUE is the maximum units of service providers would typically report for a specific HCPCS or CPT code. The MUEs are same provider, same patient, same date of service edits.

For example, typically providers would only ever report one unit of service for CPT code 58150 (total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]). However, in certain specific cases, a provider may need to perform a second hysterectomy for a patient with a double uterus. In that case, coders would append a modifier to override the MUE.

However, the Office of Inspector General and the Government Accountability Office determined that facilities were receiving inappropriate payment by reporting the same codes as separate line items.

CMS has published some, but not all, MUEs. CMS will not publish the MUEs that will be done by date of service.

From http://justcoding.com/print/289367/healthcare-news-cms-announces-change-to-medicare-claims-editing.